Complete Healthcare Compliance Manual

A&R

Audit & Reimbursement

AAFP

American Academy of Family Physicians

AAHA

American Association of Homes for the Aging

AAHP

American Association of Health Plans

AAMC

Association of American Medical Colleges

AAO

American Academy of Ophthalmology

AAP

American Academy of Pediatrics

AAPC

American Association of Professional Coders

AAPCC

Adjusted Average Per Capita Cost

ABA

American Bar Association

ABN

Advanced Beneficiary Notice

ABR

American Board of Radiology

ABS

Annual Beneficiary Summary

AC

Actual Charge

ACA

Patient Protection & Affordable Care Act (also PPACA)

ACC

Automated Change Control

ACE

Affiliated Covered Entity

ACE

(Carrier) Automated Claims Examination

ACER

Annual Contractor Evaluation Report

ACMP

Audit/Civil Monetary Penalties

ACMS

Advanced Cost Management Systems

ACO

Accountable Care Organization

ACR

Adjusted Community Rate

AD

Admitting Diagnosis

ADA

American Dental Association

ADA

American Dietetic Association

ADA

Americans with Disabilities Act of 1990

ADAMHA

Alcohol, Drug Abuse & Mental Health Administration

ADG

Ambulatory Diagnostic Group

ADG-HOSDOM

Ambulatory Diagnostic Group Hospital Dominant

ADHA

American Dental & Hygienists Association

ADJ

Adjusted Claim

ADMC

Advance Determination of Medicare Coverage

ADT

Admission/Discharge Transfer

AFEHCT

American Federation of Electronic Health Care Transactions

AFEHCT

Association for Electronic Health Care Transactions

AFHHA

American Federation of Home Health Agencies

AHA

American Hospital Association

AHCA

American Health Care Association

AHIMA

American Health Information Management Association

AHRQ

Agency for Healthcare Research and Quality

AIC

Amount In Controversy

AKS

Anti-Kickback Statute

ALBN

Amount of Last Billing Notice

ALC

Alternate Level of Care

ALOS

Average Length of Stay

ALT

Average Length of Treatment

AMA

American Medical Association

AMASDS

Asset Management & Automated Software Distribution System

AMCS

Automated Medical Coding System

AMRA

American Medical Records Association

AN

Account Number (also A/N)

ANA

American Nurses Association

AOPA

American Orthotic & Prosthetic Association

APA

American Pharmaceutical Association

APA

American Psychiatric Association

APACHE

Acute Physiology & Chronic Health Evaluation

APC

Ambulatory Payment Class

APG

Ambulatory Patient Group

APG

Ambulatory Payment Group

APM

Admission Pattern Monitoring

APM

Audit Priority Matrix

APMA

American Podiatric Medical Association

APME

Advisory Panel on Medicare Education

APR - DRG

all payer refined - diagnosis related groups

APS

Acquisition Planning Schedule

AQI

Audit Quality Initiative

AQL

Acceptable Quality Level

AQRP

Audit Quality Review Program

AR

Accounts Receivable

ASCA

Administrative Simplification Compliance Act

ASCII

American Standard Code for Information Interchange (see ANSCII)

ASCW

Audit Selection Criteria Worksheet

ASH

Assistant Secretary for Health

ASHP

American Society of Health Systems Pharmacists

ASHP

American Society of Hospital Pharmacists

ASHRM

American Society of Healthcare Risk Management

ASIM

American Society of Internal Medicine

ASTER

Automated System for Transaction Exception Resolution

ATARS

Audits Tracking & Reporting System

BA

Business Associate

BAC

Billing Action Code

BMACS

Part B Medicare Automated Claims Systems

BOME

Bureau of Medical Examiners

BP

Business Partner

BPST

Bill Processing System Test

BQAS

Part B Quality Assurance System

BSR

(Part B) Bill Summary Records

BUR

Billing Update Record

CA

Claims Analyst

CAH

Critical Access Hospital

CAHPS

Consumer Assessment of Health Plan Survey

CAP

Corrective Action Plan

CAPS

Claims Automated Processing System (SSA MBR)

CAR

Corrective Action Review

CB

Consolidated Billing

CB

Cost Benefit

CBA

Cost/Benefit Analysis

CBR

Cost Based Reimbursement

CBSS

Customer Billing Services System

CC

Claims Control

CCI

Correct Coding Initiative

CCP

Comprehensive Compliance Program

CCP

Coordinated Care Plans

CCR

Coverage Compliance Reviews

CDC

Center for Disease Control

CDM

(Hospital) Charge Description Master (Files)

CDOC

Covered Days of Care

CDRG

Children's Diagnosis Related Groups

CE

Covered Entity

CERT

Comprehensive Error Rate Testing

CHAMPUS

Civilian Health and Medical Program of the Uniformed Services

CHC

Community Health Center

CHC

Comprehensive Health Center

CHC

Continuous Home Care

CHCC

Center for Hospital & Community Care

CHCL

Center for Health Care Law

CHDS

(National) Charge Distribution System

CHHA

Certified Home Health Agency

CHHC

Continuous Home Health Care

CHIM

Center for Healthcare Information Management

CHIME

College of Healthcare Information Management Executives

CHIP

Child Health Insurance Program

CHO

Community Health Organization

CIN

Common Identification Number

CIP

Claims In Process

CLCCP

Comprehensive Limiting Charge Compliance Program

CLFS

Clinical Laboratory Fee Schedule

CLIA

Clinical Laboratory Improvement Act (of 1965) (Amendments 1988)

CLIA

Clinical Laboratory Interstate Act (or Amendments)

CLOE

(Carrier) Claims Only Entry System

CLT

Certified Lab Technician

CMHC

Community Mental Health Center (or Clinic)

CMN

Certified Medical Necessity

CMP

Civil Monetary Penalty

CMPL

Civil Monetary Penalty Law

CMPL

Civil Monetary Penalty Liability

CMPTS

Civil Monitory Penalty Tracking System

CMS

Centers for Medicare & Medicaid Services

CN

Claim Number (also C/N)

CNH

Community Nursing Home

CO

Change Order

COBRA

Consolidated Omnibus Budget Reconciliation Act (of 1985)

COI

Conflict of Interest

COP

Conditions of Participation

CORF

Comprehensive Outpatient Rehabilitation Facility

CORTS

Calculation of Overpayment Recovery Timeliness System

COSO

Commission of Sponsoring Organizations

CP

Claims Processing

CPAP

Common Provider Audit Program

CPAS

Claims Processing Assessment System

CPM

Claims Processing Manual

CPT

Common Procedural Terminology

CPT

Current Procedural Terminology

CPT-4

Current Procedural Terminology, Version 4

CQI

Continuous Quality Improvement

CR

Change Request

CR

Cost Report

CRAG

Contractor Risk Assessment Guide

CREP

Cost Report Evaluation Program

CRF

Change Request Form

CS

Claims Services

DATAMED

Medicaid Quality Control System

DEA

Drug Enforcement Administration (or Agency)

DEFRA

Deficit Reduction Act of 1984

DHS

Designated Health Services (Stark Law)

DME

Durable Medical Equipment

DME MAC

Duable Medical Equipment Medicare Administrative Contractor

DMEFS

Durable Medical Equipment Fee Schedule

DMEPOS

Durable Medical Equipment Prosthetic, Orthotics, and Supplies

DMERC

Durable Medical Equipment Regional Carrier

DOD

Department of Defense

DOJ

Department of Justice

DRG

Diagnostic Related Group (patients with similar illness)

DSCSA

Drug Supply Chain Security Act

DSH

Disproportionate Share Hospital

DSM

Diagnostic & Statistical Manual

DSM-IV

Diagnostic & Statistical Manual of Mental Disorders, 4th Edition

EACH

Essential Access Community Hospital

ED

Emergency Department

EFT

Electronic Funds Transfer

EFTS

Electronic File Transfer System (GHP large volume transfer to HDC)

EFTS

Electronic Funds Transfer System

EH

Emergency Hospital

EMB

Eligible Medicare Beneficiary

EMEVS

Electronic Medicaid Eligibility Verification System

EMT

Emergency Medical Technician

EMTALA

Emergency Medical Treatment and Active Labor Act or Emergency Medical Treatment and Labor Act

EOB

Explanation of Benefits

EOC

Episode of Care

EOMB

Explanation of Medical Benefits

ePHI

Electronic Protected Health Information

ERISA

Employee Retirement Income Security Act

ERM

Enterprise Risk Management

EVS

Eligibility Verification System

EWU

Equivalent Work Unit

F&A

Fraud & Abuse

FAH

Federation of American Hospitals

FAHS

Federation of American Health Systems

FAP

Financial Assistance Policy

FBI

Federal Bureau of Investigation

FCA

False Claims Act

FDA

Food & Drug Administration

FERA

Fraud Enforcement Recovery Act

FERPA

Family Education Privacy Rights Act

FFS

Fee for Service

FMV

Fair Market Value

FOIA

Freedom of Information Act

FQHC

Federally Qualified Health Center

FSGO

Federal Sentencing Guidelines for Organizations

FTC

Federal Trade Commission

FTP

File Transfer Protocol

GAO

Government Accounting Office

GCP

Good Clinical Practice

GHP

Group Health Plan

GHPPS

Group Health Plan Payment System

GLP

Good Laboratory Practice

GPO

Group Purchasing Organization

GSA

General Services Administration

HAASC

Hospital Affiliated Ambulatory Surgical Center

HBP

Hospital Based Physician

HCE

Hybrid Covered Entity

HCFA

Health Care Financing Administration

HCPC

HCFA Common Procedure Code

HCPCS

Healthcare Common Procedure Coding System

HCQII

Health Care Quality Improvement Initiative

HCQIP

Health Care Quality Improvement Program

HEAT

Health Care Fraud Prevention and Enforcement Action Team

HFMA

Healthcare Financial Management Association

HHA

Home Health Agency

HHABN

Home Health Advanced Beneficiary Notice

HHC

Home Health Care

HHQI

Home Health Quality Initiative

HHS

Department of Health and Human Services

HHS

Home Health Services

HIM

Health Information Management

HIPAA

Health Insurance Portability & Accountability Act of 1996

HPMP

Hospital Payment Monitoring Program

HPMS

Health Plan Management System

HIPPS

Health Insurance Prospective Payment System, a CMS payment code system

HITECH

Health Information Technology for Economic and Clinical Health Act

HITRUST

Health Information Trust Alliance

HMO

Health Maintenance Organization

HMO/CMP

HMO Competitive Medical Plan

HMODR

CMS Medicare Outpatient Data Review

HRSA

Health Resources and Services Administration

ICAR

Immediate Corrective Action Required

ICD

International Classification of Diseases

ICD-10-CM

International Classification of Diseases, Tenth Revision, Clinical Modification

ICD-10-PCS

International Classification of Diseases, 10th Revision, Procedure Coding System

ICF

International Classification of Functioning, Disability and Health

ICR

Incomplete Claims Reject

IP/SNF

Inpatient SNF

IRB

Institutional Review Board

IRF

Inpatient Rehabilitation Facility

IRO

Independent Review Organization

IRP

Incentive Reward Program

JAMA

Journal of the American Medical Association

JC/JCAHO

Joint Commission or Joint Commission on Accreditation of Healthcare Organizations

L-H

Labor Hour

LCD

Local Coverage Determination

LEIE

List of Excluded Individuals & Entities

LoProCo

Low Probability of Compromise (in HIPAA)

LTC

Long Term Care

LTCF

Long Term Care Facility

LTCU

Long Term Care Unit

M&M

Medicare & Medicaid

M+C

Medicare + Choice

M+C NSF

Medicare + Choice National Standard Format

M+CO

Medicare + Choice Organization

MA

Medicaid Agency

MA

Medicare Advantage (formerly Medicare+Choice)

MA BSF

Medicare Advantage Benefit Stabilization Fund

MA-PD

Medicare Advantage Prescription Drug Plans

MAC

Medicare Administrative Contractor

MAO

Medicare Advantage Organization

MAPD

Medicare Advantage Prescription Drug

MBD

Medicaid Beneficiary Database

MBN

Medicare Benefit Notice

MCE

Medicare Code Editor

MCM

Medicare Carrier Manual

MC

Medicare

MCO

Managed Care Organization

MCPS

Medicare (Part A) Claims Processing System (Veritus)

MCS

Mandatory Claim Submission System

MDC

Major Diagnosis Category

MDH

Medicare Dependent Hospital

MDSRH

Medicare Dependent Small Rural Hospital

MED-ED

Medical Education

MEDB

Medicare Part B

MEDPAC

Medicare Payment Advisory Commission

MFCU

Medicaid Fraud Control Unit

MFS

Medicare Fee Schedule

MFSDB

Medicare Fee Schedule Database

MHB

Maximum Hospital Benefit

MIP

Medicare Integrity Program

MMCQI

Medicare Managed Care Quality Improvement

MN

Medical Necessity

MPD

Medicare Provider Database

MPDB

Medicare Prescription Drug Beneficiaries

MPFS

Medicare Physician Fee Schedule

MQA

Medicare Quality Assurance (CWF data validation)

MQAG

Medicare Quality Advisory Group

MQC

Medicaid Quality Control

MQM

Medicare Quality Monitor

MR/UR

Medical Review / Utilization Review

MRRS

Medicaid Retrospective Reimbursement System

MSHIP

Medicare Supplemental Health Insurance Programs

MTAG

Medicare Technical Advisory Group

MTOP

Multiple Type of Provider

NAATP

National Association of Addiction Treatment Providers

NACHC

National Association of Community Health Centers

NACHRI

National Association of Children's Hospitals & Related Institutions

NAHC

National Association for Home Care

NAHDO

National Association of Health Data Organizations

NAMES

National Association of Medical Equipment Suppliers

NAPH

National Association of Public Hospitals

NAPHS

National Association of Psychiatric Health Systems

NARA

National Association of Rehabilitation Agencies

NARF

National Association of Rehabilitation Facilities

NAS

National Academy of Sciences

NASMD

National Association of State Medicaid Directors

NCCLS

National Council of Clinical Laboratory Services

NCD

National Coverage Determination

NCHS

National Center for Health Statistics

NCQA

National Committee for Quality Assurance

NCQHC

National Committee for Quality Health Care

NDC

National Drug Code

NDPS

National Drug Pricing System

NH

Nursing Home

NHA

Nursing Home Administrator

NHB

National Health Board

NHO

National Hospice Organization

NIA

National Institute on Aging

NIAID

National Institute of Allergies & Infectious Diseases

NIAMSD

National Institute of Arthritis & Musculoskeletal & Skin Diseases

NIDA

National Institute on Drug Abuse

NIDDKD

National Institute of Diabetes, Digestive & Kidney Diseases

NIDR

National Institute of Dental Research

NIH

National Institutes of Health

NIMBE

Not Including Medicare Benefits Exhausted

NIMH

National Institute of Mental Health

NIMMS

National Integrated Medicaid Management System

NINDS

National Institute of Neurological Disorders & Stroke

NIOSH

National Institute for Occupational Safety & Health

NIST

National Institute of Standards & Technology

NLN

National League of Nursing

NMC

National Maintenance Contractor

NME

National Medical Enterprises

NMEP

National Medicare Education Program

NMFA

National Medicare Fraud Alert

NMFAI

National Medicaid Fraud & Abuse Institute

NMUD

National Medicare Utilization Database

NODMAR

Notice of Discharge & Medicare Appeal Rights

NOU

Notice of Utilization

NP

Nurse Practitioner

NP/PA

Nurse Practitioners / Physician Assistants

NPF

National Provider File

NPI

National Provider Identifier

NPRM

National Provider Reimbursement Manual

NRC

National Research Council

NTH

NonTransplant Hospital

NUBC

National Uniform Billing Committee

OAC

OASIS Automation Coordinator

OASIS

Outcome & Assessment Information Set

OBQI

Outcome Based Quality Improvement

OBQIM

Outcome Based Quality Improvement Management

OBQM

Outcome Based Quality Monitoring

OBRA

Omnibus Budget Reconciliation Act

OCE

Outpatient Code Editor (System)

OCESAA

Omnibus Consolidated & Emergency Supplemental Appropriations Act for FY 1999

OCFAA

Office of Civil Fraud & Administrative Adjudication

OCR

Office for Civil Rights

ODL

Outpatient Diagnostic Laboratory

OEP

Open Enrollment Period

OFCCP

Office of Federal Contract Compliance Programs

OGE

Office of Government Ethics

OHCA

Organized Health Care Arrangements

OHRP

Office for Human Research Protections

OIG

Office of the Inspector General

OLTC

Other Long Term Care

OMIG

Office of the Medicaid Inspector General

OP

Outpatient

OP

Overpayment

OPAC

Online Payment & Accounting Collection (System) (Treasury)

OPD

OutPatient Department

OPDIV

OPerating DIVision

ORF

Outpatient Rehabilitation Facility

P&E

Parenteral & Enteral

P&T

Pharmaceutical and Therapeutic

P/B

Provider / Beneficiary

PARD

Provider Audit & Reimbursement Department

PARL

Physician/Supplier Assignment Rate List

PART A

Medicare Hospital Insurance

PART B

Medicare Supplementary Medical Insurance

PAYERID

Payer Identification (national provider identifier initiative)

PBC

Premium Billing Code

PBGC

Pension Benefit Guaranty Corp.

PBIS

PerformanceBased Incentive System

PBP

Provider Based Physician

PCH

Primary Care Hospital

PCP

Primary Care Physician (or Provider)

PCPR

Provider Claims Processing Requirements

PDMA

Prescription Drug Marketing Act of 1988

PDP

Prescription Drug Plan

PEBTAG

Provider Electronic Billing Technical Advisory Group

PEPPER

Program for Evaluating Payment Patterns Electronic Report

PFCRA

Program Fraud Civil Remedies Act

PHI

Protected Health Information

PHRMA

Pharmaceutical Manufacturers and Researchers of America

PHY/SUP

Physician/Supplier

PIG

Program Integrity Group, OFM, CMS

PIM

Medicare Program Integrity Manual

PIPDCG

Principal Inpatient Diagnostic Cost Group

POC

Plan of Care

POL

Physician Office Laboratories

POMS

Program Operations Manual System (SSA) (formerly Claims Manual CM))

POR

Provider Overpayment Recovery

POR

Provider Overpayment Report

PORS

Provider Overpayment Recovery System

PORS

Provider Overpayment Reporting System

POT

Plan of Treatment

PPACA

Patient Protection & Affordable Care Act (also ACA)

PPC

Processing Payment Cycle

PPG

Primary Care Physician Groups

PPS

Prospective Payment System (Medicare Part A)

PPSA

Physician Payment Sunshine Act

PQRS

Physician Quality Reporting System

PRM

Provider Reimbursement Manual

PRMDS

Provider Minimum Data Set

PRS

Payment Reconciliation System

PS&RR

Provider Statistical & Reimbursement Report

PSPRICE

Physician Fee Schedule System

PTA

Part A (of Medicare)

PTAMUS

Part A Medicare Utilization System

PTB

Part B (of Medicare)

QMB

Qualified Medicare Beneficiaries

RA

Risk Assessment

RAAC

Risk Adjustment Advisory Committee

RAC

Reimbursement Advisory Committee

RADV

Risk Adjustment Data Validation

RAPS

Risk Adjustment Processing System

RAPS

Risk Adjustment Processing System

RAS

Risk Adjustment System

RCL

Routine Cost Limit

RCP

Reasonable Charge Pricing

RCT

Randomized Clinical Trials

RH

Rural Hospital

RHC

Rural Health Center

RHC

Rural Health Claim

RHC

Rural Health Clinic

RHP

Rebundling of Hospital Payment

RMFA

Restricted Medicare Fraud Alert

ROAR

Recovery of Overpayments Accounting & Reporting System (SSA)

ROAR

Regional Office Automating Representatives for Managed Care Operations (ROAR for MCO)

RPCH

Regional Primary Care Hospital

RPCH

Rural Primary Care Hospital

RTP

Return To Provider (or Plan)

SA

Settlement Agreement

SMG

State Medicaid Group

SMM

State Medicaid Manual

SNC

Skilled Nursing Care

SNF

Skilled Nursing Facility

SOM

State Operations Manual

SRA

Significant Regulatory Actions

SSA

Social Security Act

SSA

Social Security Administration

SSA

State Survey Agency

SSH

Short Stay Hospital

T18

Title XVIII of the Social Security Act (Medicare)

T19

Title XIX of the Social Security Act (MAA (Medicaid))

UPL

Upper Payment Limit (Medicaid)

UR

Utilization Review

URAC

Utilization Review Accreditation Commission

WHO

World Health Organization

WPA

Whistleblower Protection Act